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Reunion Weekend 2013 Registration
For Classes 1978, 1983, 1988, 1993 and 2003


Registration Deadline is June 7th
Registration implies the consent of the registrant and adult guest(s) for the use of photographic images on the School of Medicine alumni web page and in Aspects magazine.

Alumni Information
* Required Field      
First Name *
(for badge)
Last Name *
Maiden Name
(or name at time of graduation)
   
Class Year* Specialty
Mailing Address * City *
State / Province * Postal Code *
Home Phone*
area code, prefix, number
Preferred Email *
Business Phone
area code, prefix, number
Secondary Email
Cell Phone
area code, prefix, number
   
Spouse / Guest
Check one:  Spouse Guest    
Is your spouse/guest an SIU SOM Alumni? If so, what year?
First Name
(for badge)
Last Name
(for badge)
Children
Are your children attending with you?
Yes No
 
If so, please tell us their full names, birth date (including years) and gender

 

Children's Names

Birth Date

Gender

 
 
 
 
 
 
Special Needs
Pursuant to the Americans with Disabilities Act, please advise if you or your guest(s) require special assistance to fully participate in reunion activities. Please communicate any food allergies, request vegetarian selections for any of the reunion events, or indicate special needs in the text box below. Please specify which guest has special needs.
 
Events
Friday, June 21
  Reception - Complimentary
  How many will attend?
  Adults & children 13 and up  
  Children 6-12?

  Children 0-5?  
  Of the children listed above, how many would like to:
  Play Games Children must be accompanied by an adult.
  Swim Children must be accompanied by an adult.
  Complimentary shuttle to / from Island Bay Yacht Club will be provided.
Shuttle will depart Hilton Hotel between 6:10 - 7:00 p.m. and return at 8:30 and 9:00 p.m.
  Will you use the shuttle service? * Yes No
  If so, how many passengers ?
 
Questions

If you have any questions please enter here:

 
Biosketch Info
Please share your current practice / professional information:

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Career Summary (include any leadership positions you hold or have held):

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Memorable moments and activities in medical school:

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Most interesting/daring thing I’ve done since medical school:

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